Editing Fundamentals of Nursing – RN Practice Questions (section)

==Question 6==
A registered nurse is evaluating outcomes for a patient whose goal was to ambulate 100 feet with a walker by postoperative day three. On day three the patient ambulates 40 feet and stops because of fatigue. What should the nurse do next?
# Document that the outcome was met.
# Discontinue the goal because the patient cannot achieve it.
# Reassess the patient and revise the plan of care.
# Delegate ambulation to assistive personnel more frequently.

'''Answer:''' 3. Reassess the patient and revise the plan of care.

''Rationale:'' Evaluation determines whether an outcome was met, partially met, or not met. When an outcome is only partially met, the nurse returns to assessment to identify why, such as pain, anemia, deconditioning, or hypoxia, and then revises the diagnosis, the outcome, or the interventions. The nursing process is cyclical. Option 1 is inaccurate documentation. Option 2 abandons a reasonable goal rather than adjusting it. Option 4 is an intervention chosen before the cause is understood, and ambulation frequency may not be the problem.